Health system response to COVID-19 among primary health care units in Ethiopia: A qualitative study

Introduction There was limited data on the experiences and roles of sub-national health systems in the response against COVID-19 in Ethiopia. This study explored how sub-national primary health care units and coordinating bodies in Ethiopia responded to COVID-19 during the first 6 months of pandemic. Methods We conducted a qualitative study with descriptive phenomenological design using 59 key informants that were purposively selected. The interviews included leaders across Ethiopia’s 10 regions and 2 administrative cities. Data were collected using a semi-structured interview guide that was translated into a local language. The interviews were conducted in person or by phone. Coding and categorizing led to the development of themes and subthemes. Data were analyzed using thematic analysis. Results Local administrators across different levels took the lead in responding to COVID-19 by organizing multisectoral planning and monitoring committees at regional, zonal and woreda (district) levels. Health leaders reacted to the demand for an expanded workforce by reassigning health professionals to COVID-19 surveillance and case management activities, adding COVID-19-related responsibilities to their workloads, temporarily blocking leave, and hiring new staff on contractual basis. Training was prioritized for: rapid response teams, laboratory technicians, healthcare providers assigned to treatment centers where care was provided for patients with COVID-19, and health extension workers. COVID-19 supplies and equipment, particularly personal protective equipment, were difficult to obtain at the beginning of the pandemic. Health officials used a variety of means to equip and protect staff, but the quantity fell short of their needs. Local health structures used broadcast media, print materials, and house-to-house education to raise community awareness about COVID-19. Rapid response teams took the lead in case investigation, contact tracing, and sample collection. The care for mild cases was shifted to home-based isolation as the number of infections increased and space became limited. However, essential health services were neglected at the beginning of the pandemic while the intensity of local multisectoral response (sectoral engagement) declined as the pandemic progressed. Conclusions Local government authorities and health systems across Ethiopia waged an early response to the pandemic, drawing on multisectoral support and directing human, material, and financial resources toward the effort. But, the intensity of the multisectoral response waned and essential services began suffering as the pandemic progressed. There is a need to learn from the pandemic and invest in the basics of the health system–health workers, supplies, equipment, and infrastructure–as well as coordination of interventions.


Introduction
There was limited data on the experiences and roles of sub-national health systems in the response against COVID-19 in Ethiopia. This study explored how sub-national primary health care units and coordinating bodies in Ethiopia responded to COVID-19 during the first 6 months of pandemic. Methods We conducted a qualitative study with descriptive phenomenological design using 59 key informants that were purposively selected. The interviews included leaders across Ethiopia's 10 regions and 2 administrative cities. Data were collected using a semistructured interview guide that was translated into a local language. The interviews were conducted in person or by phone. Coding and categorizing led to the development of themes and subthemes. Data were analyzed using thematic analysis. Results Local administrators across different levels took the lead in responding to COVID-19 by organizing multisectoral planning and monitoring committees at regional, zonal and woreda (district) levels. Health leaders reacted to the demand for an expanded workforce by reassigning health professionals to COVID-19 surveillance and case management activities, adding COVID-19-related responsibilities to their workloads, temporarily blocking leave, and hiring new staff on contractual basis. Training was prioritized for: rapid response teams, laboratory technicians, healthcare providers assigned to treatment centers where care was provided for patients with COVID-19, and health extension workers. COVID-19 supplies and equipment, particularly personal protective equipment, were difficult to obtain at the beginning of the pandemic. Health officials used a variety of means to equip and protect staff, but the quantity fell short of their needs. Local health structures used broadcast media, print materials, and houseto-house education to raise community awareness about COVID-19. Rapid response teams took the lead in case investigation, contact tracing, and sample collection. The care for mild cases was shifted to home-based isolation as the number of infections increased and space became limited. However, essential health services were neglected at the beginning of the pandemic while the intensity of local multisectoral response (sectoral engagement) declined as the pandemic progressed. Conclusions Local government authorities and health systems across Ethiopia waged an early response to the pandemic, drawing on multisectoral support and directing human, material, and financial resources toward the effort. But, the intensity of the multisectoral response waned and essential services began suffering as the pandemic progressed. There is a need to learn from the pandemic and invest in the basics of the health system -health workers, supplies, equipment, and infrastructure -as well as coordination of interventions.  Yes -all data are fully available without restriction Describe where the data may be found in full sentences. If you are copying our sample text, replace any instances of XXX with the appropriate details.
If the data are held or will be held in a public repository, include URLs, accession numbers or DOIs. If this information will only be available after acceptance, indicate this by ticking the box below. For example: All XXX files are available from the XXX database (accession number(s) XXX, XXX. There was limited data on the experiences and roles of sub-national health systems in the response 10 against COVID-19 in Ethiopia. This study explored how sub-national primary health care units and 11 coordinating bodies in Ethiopia responded to COVID-19 during the first 6 months of pandemic. 12 Methods 13 We conducted a qualitative study with descriptive phenomenological design using 59 key informants 14 that were purposively selected. The interviews included leaders across Ethiopia's 10 regions and 2 15 administrative cities. Data were collected using a semi-structured interview guide that was translated 16 into a local language. The interviews were conducted in person or by phone. Coding and categorizing 17 led to the development of themes and subthemes. Data were analyzed using thematic analysis. 18

19
Local administrators across different levels took the lead in responding to COVID-19 by organizing 20 multisectoral planning and monitoring committees at regional, zonal and woreda (district) levels. to obtain at the beginning of the pandemic. Health officials used a variety of means to equip and 28 protect staff, but the quantity fell short of their needs. Local health structures used broadcast media, 29 print materials, and house-to-house education to raise community awareness about COVID-19. Rapid 30 response teams took the lead in case investigation, contact tracing, and sample collection. The care for 31 mild cases was shifted to home-based isolation as the number of infections increased and space became 32 limited. However, essential health services were neglected at the beginning of the pandemic while the 33 intensity of local multisectoral response (sectoral engagement) declined as the pandemic progressed. 34 Conclusions 35 Local government authorities and health systems across Ethiopia waged an early response to the 36 pandemic, drawing on multisectoral support and directing human, material, and financial resources 37 toward the effort. But, the intensity of the multisectoral response waned and essential services began 38 suffering as the pandemic progressed. There is a need to learn from the pandemic and invest in the 39 basics of the health system -health workers, supplies, equipment, and infrastructure -as well as 40 coordination of interventions. 41

Introduction
This qualitative analysis was conducted using the transcripts of fifty-nine (59) health care professionals 137 that participated in the study. This was less than the expected (60). In one of the regions only four out 138 of five expected participants were available for the interviews. Eighty-nine percent of the participants 139 were male. Participants ranged substantially in age, with a mean age of 35 years. Forty four percent of 140 the health facilities were well represented in the sample. Participants were in senior leadership or 141 management positions, but, on average, had been on the job less than five years ( The administrative bodies -from regional councils to lowest administrative units (kebeles) -formed 171 coordination committees. The heads of administrative bodies presided over these coordinating bodies 172 (multisectoral committees) that planned, organized, and monitored local responses. Different sectors 173 were represented on these committees, including health; education; finance; law enforcement; water, 174 irrigation and electricity; and trade. These committees were called taskforces and were established all-175 over the regions depending on their sector arrangements. The taskforces met regularly and in some 176 cases they met every three days. 177 Sub-committees or technical committees were also formed to implement specific tasks. Key 178 informants frequently cited the finance or resource mobilization sub-committee, which was responsible 179 for obtaining support -in cash and kind -from local governments, non-governmental organizations, and 180 community members. The coordination committees also raised and directed resources to the most 181 vulnerable members of their communities including people living with daily subsistence, long distance 182 drivers, police stations, and street dwellers. For instance, one of the respondents replied, "Another 183 committee established by the mayor was the resource mobilization committee, which includes the finance and health 184 sectors, and coordinates resource mobilization to purchase personal protective equipment like facemasks and provides 185 support for community members who are seriously affected." (Sidama, Zonal Health Department).

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Surveillance was a key focus of incidence management teams across regions, particularly at the 187 woreda level. At higher levels, the initial focus was on operations: assessing the extent of need for and 188 setting up quarantine, isolation, and treatment centers; customizing or developing guidelines for health 189 workers; and expanding screenings at major entry points. Health centers organized rapid response 190 teams to conduct case finding and contact tracing in their communities. 191 "Before health centers began any activity, they organized committees. The

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Health workforce: As most key informants described, health leaders responded to the heightened 199 demand for healthcare workers in two ways: 1) by redeploying or adding responsibilities to the existing 200 workforce, and 2) by hiring new workers. Often, authorities adopted the first approach. Health 201 professionals from hospitals and health centers were redeployed to isolation and treatment centers, 202 rapid response teams (RRT), and care teams for patients in home-based isolation. They were also 203 asked to serve in woreda health offices and regional health bureaus as members of planning and 204 coordination teams. 205 Health extension workers, who were already engaged in community education, mobilization 206 and prevention activities, added COVID-19 related tasks to their day-to-day activities by leading 207 community-based education, screening efforts and assisting RRPs with contact tracing. The added 208 responsibilities created pushback: "Most services, including community services and COVID, rest on the 209 shoulders of the health extension workers. That is why they complained about the work burden." (Sidama 210 Health Facility 2). 211 To maintain the capacity of the existing workforce, the health system instituted a 'no leave 212 policy' that denied health workers their annual leave. "Annual leave was prohibited to all professionals 213 because if all professionals were not working together, the pandemic could affect many people." (Harari, 214 Regional Health Bureau). However, during the state of emergency, certain categories of workers -215 pregnant and lactating women and providers with chronic conditions -were ordered to stay home. 216 Additionally, health authorities in Addis Ababa, Afar, Benishangul-Gumuz, Oromia, Southern 217 Nations, Nationalities and Peoples' (SNNP), and Tigray regions hired new staff. They received money 218 from the regional health bureau, regional government, or Ministry of Health to increase their health 219 workforce, but often temporarily. The new hires were largely professionals -medical doctors, health 220 officers, environmental health experts, laboratory technicians, and nurses. Despite the investment in 221 health professionals, key informants in Addis Ababa complained of a severe shortage of urban health 222 extension workers in the capital. 223 Training: Training for the health workers focused on key pillars of COVID-19 response -surveillance 224 (specifically, case investigation by RRTs), infection prevention and control, community education, and 225 case management. Health authorities relied on the train-the-trainer model to transfer skills and 226 information from regional health bureaus down to health centers and health posts. More often, 227 however, regional health authorities suspended the linear train-the-trainer model and directly offered 228 training to staff at lower levels. 229 Content specific trainings were organized for RRTs, staff working at quarantine, isolation and 230 treatment centers, laboratory technicians, and health extension workers. In Amhara, informants 231 mentioned that influential community members and health professionals from the private sector were 232 also invited to participate in trainings, particularly on infection prevention and control (IPC). The 233 duration of trainings differed based on the topic. Trainings were held online, in venues that were large 234 enough to meet physical distancing requirements, or on-site. 235 In most regions, trainings organized by regional or zonal offices were supported by partner 236 institutions and local universities. In addition, WHO, EPHI and MOH provided technical support. 237 COVID-19 supplies and equipment: Health officials and providers across the country noted a 238 shortage of COVID-19 supplies and equipment, particularly PPE, at the beginning of the pandemic. For 239 some, access to PPE remained a problem as late as September/October 2020. Health officials reported 240 that, initially, they faced a shortage of facemasks and protective gowns, and to a lesser extent, gloves. In 241 addition, they lacked the beds, linens, and medical devices needed to furnish isolation and treatment 242 centers. Hand sanitizers and cleaning materials were also in short supply. A zonal health official in 243 Tigray spoke about their struggle to obtain reagents for laboratories. Problems accessing non-PPE 244 materials, however, were not uniform: materials that were scarce in one region were available in 245 others. For example, a zonal health official in Addis Ababa stated "There were no problems with 246 sanitizers." While, according to a health center director in Harari, "There was a greater shortage of 247 sanitizers than gloves." 248 In the early months of the pandemic, the challenge in purchasing COVID-19 supplies and 249 equipment, particularly PPE, was largely due to mismatch in supply and demand. The demand for 250 facemasks, gloves, and sanitizers outpaced their production. Even when health centers or offices had 251 developed and disseminated messages with support from partner organizations and local government 286 communications offices. Printed materials, radio, and television were commonly used to transmit 287 information, with higher-level offices relying on broadcast media. Regional and zonal offices ran ads on 288 local radio and television stations about the pandemic. Experts appeared on live television or radio 289 programs to answer audience questions or present the latest information about the virus. As the 290 following quote attests, collaborations with international NGOs, academic institutions, and professional 291 associations helped regional and zonal leaders to maximize their communication efforts: "We also 292 worked with the Amhara Physicians' Association, clinicians, and public health experts who made live 293 appearances on television programs in collaboration with Bahir Dar University." (Amhara, Regional Health 294 Bureau). 295 To a lesser extent, regional and zonal health offices also used social media, particularly 296 Facebook, to share information and updates. The regional health bureau in Tigray, for instance, posted 297 the daily number of confirmed cases in the region on its website and Facebook page. Visitors to these 298 sites could also find information about COVID-19 and steps local authorities were taking to contain 299 the pandemic. In addition to traditional and social media, health officials in Sidama and SNNP 300 collaborated with artists to develop music and drama about COVID-19: "Artists in the Sidama region 301 communicated messages through songs and drama, for adults and children, on how to prevent the disease." 302 (Sidama, Regional Health Bureau). A woreda health official from SNNP spoke of a "holistic" song 303 produced by senior Wolaita musicians that gained popularity with rural communities. In Oromia, 304 community and religious leaders played a role in community education. "We provided information to the 305 community through religious leaders, cultural leaders -Aba Geda, and different media. People in our region have received 306 sufficient information about prevention and have used that information to keep themselves safe." (Oromia, Regional 307 Health Bureau).

308
Woreda health offices and health centers commonly relied on printed materials (leaflets, 309 brochures, posters, and banners) to spread information about the COVID-19. Regional or zonal offices 310 created these materials in local languages and sent them to the lower tiers for distribution. Health 311 extension workers (HEWs), volunteers, and care providers handed out brochures and fliers in the 312 community and during house-to-house visits. Posters and banners were displayed in crowded markets 313 and busy streets. 314 With decentralized coordination mechanism in place (federal, regional, zonal, woreda and 315 kebele levels), intensive outreach took place at different sites -homes, work places, places of worship, 316 and health facilities. Health professionals, teachers, and volunteers visited households in Tigray and in 317 Somali regions and also health extension workers, traditional birth attendants, and family health teams 318 visited households. Health professionals also used loud speakers, often driving through city streets or 319 villages, to maximize their reach. Health centers and woreda health offices made a deliberate effort to 320 target vulnerable communities. For example, a health center in Amhara conducted outreach to the 321 homeless and a woreda in Addis Ababa shaped its message about preventive measures to address the 322 concerns of community members with non-communicable diseases (NCDs) as they are at high risk for 323 infection. Taskforces and technical committees at woreda/health center levels coordinated all the 324 activities with the help of corresponding law enforcements. 325 Risk communication messages stressed the importance of maintaining hand hygiene (using soap 326 and water or hand sanitizers), wearing masks, keeping a physical distance. Messages also covered the 327 signs and symptoms of the disease and provided hotline numbers to call for additional information or 328 to report suspected cases. During household visits, health extension workers demonstrated proper 329 hand washing, physical distancing, and mask wearing techniques. "HEWs did house-to-house visits in their 330 assigned areas or kebeles. They supplied households with soaps and businesses with hand sanitizers. They taught 331 households how to prevent COVID-19, advised them to stay home, and to wear masks if they were in public. They also 332 gave out leaflets with the emergency telephone number." (Somali, Health Facility 2).

333
A health center in Harari encouraged community members with chronic conditions to continue 334 taking their medications. Still, financial, political, and environmental pressures placed limits on risk 335 communication efforts in some regions. A representative from the Addis Ababa regional health bureau 336 said "the rate of mass media utilization is not as expected due to the expense." Also, in Sidama, a woreda 337 health official noted that "performance was very strong initially, but it has become weak recently because of 338 cost and our lack of capacity" in reference to the use of mobile public announcement systems to 339 disseminate information about the virus. Outreach was stymied in rural parts of Harari due to security 340 issues and heavy rainfall that made roads inaccessible. 341 Health extension workers conducted house-to-house screenings in three rounds with a testing 349 campaign that occurred in August 2020. Community screenings targeted high-risk groups and places 350 where transmissions were most likely to occur: long-distance bus drivers for instance, were prioritized 351 for screening in Amhara and Tigray and screenings took place at bus station and police stations in 352

Surveillance, Rapid Response Teams, and Case Investigation
Gambella. Community members were also encouraged to contact health authorities if anyone in the 353 community showed signs or symptoms of the disease. Until 30 September 2020, a total of 1,272, 352 354 samples were tested out of which 75,368 were confirmed cases of COVID- 19. 355 Health centers set up triage areas to screen every patient who entered their compounds. 356 Screeners used a checklist to identify suspected cases. The initial screening consisted of a temperature 357 check and questions probing signs and symptoms of acute respiratory infection. Patients with fever and 358 cough were escorted to an isolation room in the health center where they were further evaluated by a 359 clinician. Patients who were suspected of COVID-19 remained in the isolation room until they were 360 tested. 361 As the number of cases that required hospitalization grew, health authorities expanded the 362 number of treatment-centers, quarantine and isolation centers in each region -often selecting schools 363 and universities (which were closed at the time (2020) after the state of emergency was declared) as 364 supplementary sites and hotels provided by local business owners. 365 Zonal health officials in Sidama opted to use space donated by local businesses for COVID-19 366 treatment rather than interrupt the delivery of essential services at health facilities. A regional health 367 bureau official in Afar reported that, "with the surge of infections, severe cases of COVID-19 were placed in 368 hospitals and milder cases were treated in non-traditional care facilities". Many health centers set up 369 isolation areas by converting a room or unused area in their facilities. In some centers, the conversion 370 of spaces encroached on existing services, as in the case of health centers in Benishangul-Gumuz where 371 waiting rooms for expectant mothers were transformed into isolation rooms for suspected COVID-19 372 cases. Isolation rooms were outfitted with beds, oxygen cylinders, and pulse oximeters in Addis Ababa 373 and Tigray. 374 The RRT was called to conduct an investigation. when there was a suspicious finding in the 375 community, The team -which typically consisted of a clinician, an epidemiologist, an environmental 376 health expert, a health educator, and a lab technician -then transported individuals suspected of 377 COVID-19 to a quarantine center where they were tested and remained until their results were 378 known. 379 Depending on the region, either staff from the EPHI or members of RRTs were responsible for 380 sample collection. In August, the federal government undertook a nation-wide campaign to gauge the 381 level of infection in the country and measure community understanding of COVID-19 prevention 382 measures. Vulnerable groups, such as those with chronic conditions, were specifically targeted for 383 testing during the campaign. 384 The RRTs were also responsible for transporting samples to the nearest laboratory. Each 385 region had at least one laboratory and many were located on the campuses of major universities. 386 Before the regional laboratories were set up, tests were sent to laboratories in Addis Ababa or outside 387 the country. Key informants in Oromia and Tigray noted that laboratories struggled to report test 388 results in a timely manner. Delays were reportedly due to a lack of coordination, limited diagnostic 389 machines, and a lack of reagents. "Quarantine is located at another site…. but the problem is test results are not 390 reported timely and a lot of complains are coming from people staying at the quarantine center. Results are being 391 reported 9 or 10 days after they are expected, which is extremely frustrating. …" (Tigray, Woreda Health Office).

393
Case management: Individuals in quarantine were released after seven days if they tested negative. 394 Otherwise, they were transferred to an isolation or treatment center. Rapid response teams 395 conducted contact tracing and suspected contacts were placed in quarantine and tested. The policy 396 changed to allow mild and asymptomatic cases to isolate at home as the state of emergency came to an 397 end and schools prepared to re-open. Rapid response teams determined who could isolate at home 398 and regularly followed-up. 399

Infection Prevention and Control:
Health centers undertook precautions to ensure the safety of 400 their workers and patients. They set up washing stations where patients were required to wash their 401 hands before proceeding to their appointments. They limited entry only to patients, placed markers 402 two meters apart so that patients could adhere to physical distancing requirements, and disinfected 403 essential departments. Some centers had two gates, one for entry and another for exit. "In addition, 404 guards were given additional work to make sure that every client entered to our health center washed 405 their hands using water and soap available at the gate". (Oromia, Facility 2). 406 In regions across Ethiopia, community-based IPC was largely the responsibility of regional, 407 zonal, and woreda health offices. Many installed handwashing facilities in crowded areas. A woreda in 408 SNNP temporarily housed "street dwellers" who were considered high-risk for infection and provided 409 them with food and hygiene materials. A zonal health department in Sidama disinfected sidewalks and 410 office buildings every 15 days. Higher-level offices collaborated with the police to enforce or promote 411 infection control measures in markets, restaurants, and passenger cars. They also organized volunteers, 412 particularly youth and members of the women's development army (volunteer community health 413 workers), to educate and encourage people to adhere to prevention strategies. 414

415
Similar to many other African countries, different regions of Ethiopia acted early by implementing 416 screening measures at airports and border crossings before the first case of coronavirus was detected 417 (40). Following the confirmation of the first case, sub-national government structures from regional 418 councils to kebeles set up multisectoral coordinating committees that were responsible for planning, 419 organizing, and monitoring local responses. Research indicates that local governments also played a 420 vital role in the pandemic response in other low-and middle-income countries. Similar to our findings, 421 studies from China and India showed that local government efforts were multisectoral and focused on 422 resource mobilization, infection control, and risk communication (41-43). A county government 423 outside Wuhan, China, for example, organized "functional groups" that, among other responsibilities, 424 procured PPE from different sources for local public hospitals and community volunteers (42). These 425 studies also found out that local governments provided aid to needy individuals and households, 426 to carry out the basic functions of disease control because they have a deeper understanding of 431 community needs, can respond more efficiently to crises, and hold greater legitimacy with constituents 432 than distant government officials (41). Unfortunately, our study showed that the role of local 433 governments was not sustained over the course of the pandemic -a finding that was not reflected in 434 other studies. This might be due to limited experience in exercising decentralization in Ethiopia and 435 lack of mechanisms to ensure continuous financial support. Furthermore, trends in international and 436 national practices could influence and this requires further investigation. Initially, the sub-national 437 response in Ethiopia also embodied a whole-of-society approach that was promoted and reflected in 438 the literature. This approach endorses collaboration across sectors based on the notion that no single 439 body or institution can capably respond to complex emergencies or social problems (44). Again, 440 studies from India and China found that local governments mobilized community members to 441 volunteer in the response effort (41,45,46). Also, a survey of medical students, health workers, and 442 community service workers in Vietnam showed strong support for involving youth groups, women's 443 associations, religious leaders, and local organizations in community education, surveillance, and 444 contact tracing during the pandemic which is similar to our study particularly at the initial phase (47). In 445 our study, participants highlighted and praised civic society institutions, volunteers, and businesses for 446 engaging in a variety of activities, ranging from community education and the provision of supplies and 447 facilities to the enforcement of infection control measures. This was a very good lesson. But, six 448 months after the start of the pandemic, the study participants observed a decline in multisectoral 449 engagement and warned of the health sector's capacity to control the pandemic in isolation. 450 Because of underinvestment in health care, many low-income countries suffer from a shortage 451 of critical health inputs including, supplies, infrastructure, and health professionals. To fill the gap in 452 human resources, for instance, experts advocate the use of community health workers in both 453 maintaining essential health services and containing the pandemic (48,49). This is viewed as a feasible 454 solution in settings where community health workers outnumber clinicians and function as trusted 455 sources of health information and services (50). 456 Our study showed that community health workers (known as health extension workers or 457 professionals) in Ethiopia were a key to COVID-19 response strategies. They engaged in community 458 education -principally through house-to-house visits -performed screenings, and assisted RRTs with 459 contact tracing. A rapid evidence synthesis found that community health workers in low-and middle-460 income countries played similar roles in the pandemic response (51). Furthermore, when essential 461 health resources showed signs of decline in Ethiopia, community health workers were tasked with 462 alleviating community members' fears of accessing health services and re-engaging patients who were 463 lost to follow-up. In many areas, responsibilities related to COVID-19 were added to their existing 464 workload, creating low morale and push-back from health extension workers as the time progressed. 465 The rapid evidence synthesis showed that improving benefits, providing training and recognizing the 466 contributions of community health workers in high-profile events could bolster their recruitment and 467 retention (51). 468 In addition to mobilizing health extension workers, sub-national health systems in Ethiopia 469 addressed the surge in the health workforce by reassigning health professionals, cancelling leaves of 470 absence, recruiting new health workers, and bringing retired or private sector professionals into the 471 workforce. While comparable research in low-income countries was not available, a study of 44 472 countries in Europe and North America showed that the governments of wealthy nations used mix of 473 policy options similar to what we found out (52). The most common strategies involved maintaining 474 the existing workforce by extending work hours, moving staff from part-time to full-time, or 475 suspending annual leaves. These governments also recruited medical and nursing students (a strategy 476 that was not mentioned by participants in our study), redeployed workers to facilities or areas with the 477 greatest need, and enlisted retired, foreign, and private sector professionals. Most countries used at 478 least two strategies. While the impact of these measures in Europe and North America has not been 479 studied, our study participants linked a weakening of the essential health services to the redeployment 480 of staff to the COVID-19 response. This might be due to inadequate strategies and financial constraints 481 in recruitment of new staff and redeployment of available health workers in Ethiopia. 482 An important factor in containing COVID-19 was protecting the health workforce from 483 infection. Study participants shared their struggles to acquire PPE, particularly facemasks and gowns, at 484 the beginning of the pandemic. Due to constraints in production, PPE was limited and costly. Ethiopia 485 was not unique in this regard; countries worldwide faced a shortage of PPE and price hikes at the start 486 of the pandemic (53). But low-income countries were disproportionately affected because of their 487 relatively weak bargaining positions in the global supply chain, low capacity in production of supplies, 488 limited purchasing power, and low hands-on reserves of PPE (54-56). 489 When production began to accelerate, study participants accessed key protective gear through 490 different means, including the engagement of local businesses. Local production of PPE was a solution 491 to the shortage in a number of low-income countries: the governments of Uganda, Tanzania, Kenya, 492 Nigeria, Liberia, and Ghana, for instance. (54-56). At a more grassroots level, a government hospital in 493 Dar es Salaam, Tanzania collaborated with seamstresses, business owners, community members, and 494 NGOs to produce reusable facemasks, gowns, scrubs and caps for its staff (55). However, reusable 495 facemasks vary in quality and may not be the best option. Reusable masks vary from homemade cloth 496 masks to masks with HEPA filter (57). In Ethiopia, despite their efforts to meet the demand for PPE, 497 most participants in our study were unsatisfied with the quantity of PPE at their disposal. Our finding is 498 corroborated by a survey of health care workers at a public hospital in Addis Ababa in which over 499 three-fourth of the respondents reported an inadequate supply of PPE at their hospital (58). 500 Risk communication and community engagement was central to the response effort in Ethiopia. 501 Regional and zonal offices used broadcast media, and to a lesser extent social media such as Facebook, 502 to disseminate information about the COVID-19. With support from international NGOs, academic 503 institutions, and professional associations, they ran ads on local television and radio stations and invited 504 experts to speak about the pandemic on broadcast media. However, risk communication efforts were 505 limited in some areas by financial, political, and environmental obstacles, Most COVID-19 related 506 studies conducted in Ethiopia examined knowledge, attitudes, and practices among community 507 members, showing generally high rates of knowledge and poor prevention practices. 508 Limitations of the study: Due to national and state level lockdowns the investigators could not go 509 out to the field thus limiting the potential for extra lens to note field observations not captured by the 510 interviews. However, the authors have tried to overcome this by assigning a supervisor for each 511 interviewer in each region. We noted that data collected from two of the regions was not good 512 enough in terms of depth and probes affecting the richness in some of the topics. This might be due to 513 lack of experience of those interviewers in applying the different techniques of qualitative methods. 514 However, the impact was minimal as the sample was large enough to explore the topics of interest. 515 Conclusions 516 Sub-national health structures waged a swift and coordinated response to COVID-19 at the start of 517 the pandemic. They drew on all available resources -from their own expertise and workforce to local 518 governments and businesses, academic institutions, and community members to mitigate the spread of 519 the virus. However, the response was strained from the beginning -due to a shortage of health 520 workers, space, equipment and supplies -and began to fray as the pandemic worsened. The 521 multisectoral response that started with strong political commitment and drove the initial response 522 declined within six months of the pandemic. As the number of infections in Ethiopia rise, we 523 recommend: reengaging local administrations and actors outside the health sector, including academic 524 institutions and local businesses, in the response effort; strengthening resource mobilization for 525 COVID-19 supplies and equipment; improving testing capacity across the country; and collaborating 526 with local media and community leaders to strengthen community adherence to prevention measures. 527 There is a need to invest in the basics of the health system -health workers, supplies and equipment, 528 and infrastructure -as well as specific interventions to intensify the COVID-19 response and restore 529 the multi-faceted response. The study has illuminated relevant lessons for future emergencies and 530 underscored engagement of local governments was a key to take immediate action and sustain the 531 local response against COVID-19. 532 Acknowledgements 535 We would like to acknowledge the study participants and their respective regional health bureaus, 536 zonal health departments, woreda health offices, and health centers for agreeing to take part in this 537 study. We are also grateful to the data collectors and supervisors, staff at Ethiopian Public Health 538

Supporting Information
Institute and the International Institute for Primary Health Care-Ethiopia for their technical support. 539                   In Ethiopia, the first case of COVID-19 was detected on March 134, 2020. In April 2020, the government issued a five-month state of emergency that closed schools and universities, banned gatherings of more than four people, ordered transportation service providers to reduce their passenger loads, prohibited sports activities, and mandated the wearing of masks in public (9-10). In collaboration with the WHO and other partners, the government also began assessing and equipping public and private laboratories to expand testing for COVID-19 (11).
Furthermore, approaches and processes to systematically mount the response against COVID-19 waswere largely unknown particularly at subnational (regional) level where most of the preventive activities are taking place. So, exploring the response including organizational approaches towards COVID-19 at subnational and primary health care (PHC) levels Inin a decentralized system such as Ethiopia exploring the response including organizational approaches towards COVID-19 at subnational (regional) and primary health care levels will offer a better picture of the process, measures undertaken to control and prevent the spread of coronavirusCOVID-19. This study is was therefore to understand the process and learn from the response towards COVID-19 pandemic at subnational level in Ethiopia considering the first 6 months of the pandemic.

Study setting:
The study was conducted in September and October of 2020 in Ethiopia's ten regions (Afar, Amhara,

Study design:
We employed descriptive qualitative (phenomenological) design to explore the Ethiopian health system's response to COVID-19 in the first six months of the pandemic.

Selection of participants and sample size:
We used purposive sampling to select a total of 59 participants. Key informants were chosen among health professionals who were actively engaged in the COVID-19 response across the country. Active engagement included direct participation in decision making pertaining to prevention and control and provision of services to patients affected by coronavirusCOVID-19. From each region and city administration, we selected one person from a regional health bureau, two persons from zonal/woreda health offices, and two from health facilities. The criteria for selection were completion of postsecondary education, current employment in the public health system and involvement in COVID-19 response. In our sampling strategy we covered all regions (subnational) of the country and followed the decentralization system with the aim of obtaining some kind degree of representation of the

Data Collection and Analysis:
We recruited and trained 12 data collectors (interviewers) and 12 supervisors. Both groups had graduate level education with some qualitative research experience. Because of government restrictions on assembly and travel, we held training for data collectors and supervisors remotely via Google Meet for half a day. The data collectors conducted interviews in person or by phone using a semi-structured interview guide that was translated into Amharic, the national language. The data collectors digitally recorded the interviews and translated and transcribed the responses into English.
The supervisors met (in person or via phone) with the data collectors each day to review the transcripts and discuss ways to improve the quality of data collection. The supervisors provided feedback and support in consultation with the PI.
The supervisors made contacts and arranged meetings, communicated with the principal investigator (PI) and checked voice records, transcripts and translated versions of the interviews. The interviewers on the other hand conducted the interviews, transcribed and translated them to English. Because of government restrictions on assembly and travel, we held a training for data collectors and supervisors remotely via Google Meet for half a day. The data collectors conducted interviews in person or by phone using a semi-structured interview guide that was translated into Amharic, the national language.

The data collectors digitally recorded the interviews and translated and transcribed the responses into
English. The supervisors met (in person or via phone) with the data collectors each day to review the transcripts and discuss ways to improve the quality of data collection. The supervisors provided feedback and support in consultation with the PI. Validity and reliability of qualitative research is measured through trustworthiness which in turn includes credibility, confirmability, transferability and dependability (37). To ensure the credibility of our findings, we recruited data collectors and supervisors who were actively working in the respective regions and who were familiar with their respective study areas and health systems. The data collectors and supervisors also received training on the purpose, methods, and tools of the study. We accounted for confirmability by capturing participants' responses through recordings and transcriptions that were checked by supervisors and read several times by investigators. The study addressed transferability by including all regions of the country as the infrastructures and context are at varying levels. We also validated the semi-structured guides through discussion with the interviewers and supervisors. For ensuring dependability, the guides for the interview included interventions and strategies recommended by the WHO and the country context. The methods and procedures applied are were consistent with other authors that conducted similar studies.

Ethical Considerationss
The proposal was approved by the Institutional Review Board of Ethiopian Public Health Institute (EPHI) (# 280-2020). All study participants provided informed verbal consent to be interviewed. Verbal consent was used to minimizse contact through paper exchange considering COVID-19 transmission. health care professionals that participated in the study. This was less than the expected (60). In one of the regions only four out of five expected participants were available for the interviews. Eighty-nine percent of the participants were male. Participants ranged substantially in age, with a mean age of 35 years. Forty four percent of the health facilities were well represented in the sample. Participants were in senior leadership or management positions, but, on average, had been on the job less than five years (Table 1).   Sub-committees or technical committees were also formed to implement specific tasks. Key informants frequently cited the finance or resource mobilization sub-committee, which was responsible for obtaining support -in cash and kind -from local governments, non-governmental organizations, communityand community members. The coordination committees also raised and directed resources to the most vulnerable members of their communities including people living with daily subsistence, small business ownerslong distance drivers, police stations, and daily laborersstreet dwellers. For instance, one of the respondents replied, "Another committee established by the mayor was the resource mobilization committee, which includes the finance and health sectors, and coordinates resource mobilization to purchase personal protective equipment like face masks and provides support for community members who are seriously affected."
The coordinating committees met regularly at the beginning of the pandemic to evaluate their work and plan next steps. As the months progressed, however, key informants from several regions noted a decline in commitment as other issues gained priority or as panic over the virus subsided.

SurveillanceIncident Management:
Surveillance was a key focus of incidence management teams across regions, particularly at the woreda level. At higher levels, the initial focus was on operations: assessing the extent of need for and setting up quarantine, isolation, and treatment centers; customizing or developing guidelines for health workers; and expanding screenings at major entry points. Health centers organized rapid response teams to conduct case finding and contact tracing in their communities.

2.1
Health workforce: As most key informants described, health leaders responded to the heightened demand for healthcare workers in two ways: 1) by redeploying or adding responsibilities to the existing workforce, and 2) by hiring new workers. Often, authorities adopted the first approach.
Health professionals from hospitals and health centers were redeployed to isolation and treatment centers, rapid response teams (RRT), and care teams for patients in home-based isolation. They were also asked to serve in woreda health offices and regional health bureaus as members of planning and coordination teams.
Health extension workers, who were already engaged in community education, mobilization and prevention activities, added COVID-19 related tasks to their day-to-day activities by leading community-based education, screening efforts and assisting rapid response teamsRRPs with contact tracing. The added responsibilities created pushback: "Most services, including community services and COVID, rest on the shoulders of the health extension workers. That is why they complained about the work burden." (Sidama Health Facility 2). The redeployment of health professionals affected the delivery of essential health services. According to a regional health bureau official in Benishangul-Gumuz, "As soon as COVID-19 occurred, by providing training, we mobilized the health workforce that was previously providing essential health services." New staff werestaff was rarely hired to replace the ones who were assigned to To maintain the capacity of the existing workforce, the health system instituted a 'no leave policy' that denied health workers their annual leave. "Annual leave was prohibited to all professionals because if all professionals were not working together, the pandemic could affect many people." (Harari, Regional Health Bureau). However, during the state of emergency, certain categories of workerspregnant and lactating women and providers with chronic conditions -were ordered to stay home.
Additionally, health authorities in Addis Ababa, Afar, Benishangul-Gumuz, Oromia, Southern Nations, Nationalities and Peoples' (SNNP), and Tigray regions hired new staff. They received money from the regional health bureau, regional government, or Ministry of Health to increase their health workforce, but often temporarily. The new hires were largely professionals -medical doctors, health officers, environmental health experts, laboratory technicians, and nurses. Despite the investment in health professionals, key informants in Addis Ababa complained of a severe shortage of urban health extension workers in the capital.

2.2
Training: Training for the health workers focused on key pillars of COVID-19 responsesurveillance (specifically, case investigation by RRTs), infection prevention and control, community education, and case management. Health authorities relied on the train-the-trainer model to transfer skills and information from regional health bureaus down to health centers and health posts. More often, however, regional health authorities suspended the linear train-the-trainer model and directly offered training to staff at lower levels.
Theoretically, teams of content experts in regional health bureaus were expected to train their counterparts in zonal health departments who, in turn, would train selected staff at woreda health offices and health centers. Trained staff from woreda health offices and health centers werestaff from woreda health offices and health centers was responsible for training colleagues in their institutions.
More often, however, regional health authorities suspended the linear train-the-trainer model and directly offered training to staff at lower levels. Regional health staff trained health professionals involved in highly technical or advanced care, such as laboratory technicians and clinicians assigned to isolation and treatment centers. In Tigray and Benishangul-Gumuz, regional health staff trained the rapid response team at a woreda health office. It was not clear why the train-the-trainer model was suspended in some cases and the impact of this decision on the efficacy of trainings was unknown.
Content specific trainings were organized for RRTs, staff working at quarantine, isolation and treatment centers, laboratory technicians, and health extension workers. In Amhara, informants mentioned that influential community members and health professionals from the private sector were also invited to participate in trainings, particularly on infection prevention and control. The duration of trainings differed based on the topic. Trainings were held online, in venues that were large enough to meet physical distancing requirements, or on-site.
In most regions, trainings organized by regional or zonal offices were supported by partner institutions and local universities. Wolaita Sodo University, Mekelle University, and Bahir Dar University, for example, assisted with trainings in SNNP, Tigray, and Amhara, respectively. In addition, The WHO, EPHI and MOH provided technical support. was cited as a partner by regional health officials in Afar and Tigray. In addition, study participants referenced EPHI and the MOH for their technical support.
A few key informants emphasized the difference between trainings -which were longer, content-specific, and detailed versus orientations, which seemed to provide an overview of COVID-19 signs and symptoms, transmission, methods of prevention and that were designed for non-technical Despite their shortcomings, key informants stressed the impact of these trainings on worker attitude and performance. "Prior to training, health professionals panicked about COVID-19. The training changed their mindsets and they now believe that it is possible to tackle this pandemic." (Benishangul-Gumuz, Regional Health Bureau).

COVID-19 supplies and equipment:
Health officials and providers across the country noted a shortage of COVID-19 supplies and equipment, particularly personal protective equipment (PPE), at the beginning of the pandemic. For some, access to PPE remained a problem as late as September/October 2020., when the interviews were conducted. Health officials reported that, initially, they faced a shortage of facemasks and protective gowns, and to a lesser extent, gloves.
Access to other supplies and equipment was also a challenge. Health officials reported that In addition, they lacked the beds, linens, and medical devices needed to furnish isolation and treatment centers. Hand sanitizers and cleaning materials were also in short supply. A zonal health official in Tigray spoke about their struggle to obtain reagents for laboratories. And health leaders in Somali and Harari regions raised concerns about their ability to deploy and transport RRTs with few cars.
Problems accessing non-PPE materials, however, were not uniform: materials that were scarce in one region were available in others. For example, a zonal health official in Addis Ababa stated "There were no problems with sanitizers." While, according to a health center director in Harari, "There was a greater shortage of sanitizers than gloves." In the early months of the pandemic, the challenge in purchasing COVID-19 supplies and equipment, particularly PPE, was largely due to mismatch in supply and demand mismatch. The demand for face masks, gloves, and sanitizers outpaced their production. Even when health centers or offices had the budget to purchase PPE, the items were not available in the market. "At the beginning it was challenging, there was almost no PPE. There was no production of PPE and supply. Even though we tried to buy from the market, it was not available. Later when we invested in PPE -sanitizers, masks and other items -it was challenging financially. It affected the other services significantly." (Tigray, Health Facility 1).
Health officials used different strategies to procure PPE and other needed materials. Early on, they used what they had in stock. Some repurposed materials that had been in storage for public health emergencies such as Ebola and cholera. Health centers in particular used a combination of their own revenues, shifted budget to COVID-19, and through assistance from regional health bureaus or city administrations and private donors to get needed supplies. However, regional health bureaus, zonal health departments, and woreda health offices -relied on budget allocations by administrative bodies and private donations. The shift of budget shifting from other services to COVID-19 was illustrated in the following example. re was also a shift of budget from other services to COVID-19. A regional health bureau official from Addis Ababa explained his bureau shifted their budget and "…we used finance allocated for non-COVID services to buy PPEs and other resources, which ultimately affected the essential health services….". (Addis Ababa, Health Bureau).
The private sector played a role in meeting alleviating demand-associateds shortfalls for COVID-19 supplies and equipment. Businesses, non-governmental organizations, and individuals, both in Ethiopia and abroad, were mobilized to support the health system in this effort. A zonal health leader in Amhara indicated that international non-governmental organizations (NGOs) were instrumental in procuring supplies -like alcohol and sanitizers -that were difficult for health authorities to purchase from the market. Yet, while NGOs and individuals made donations, businesses in a few regions -ranging from microenterprises in Tigray to an industrial park in Sidamamanufactured needed supplies.

Formatted: Strikethrough
In a few regions -Harari, Addis Ababa, Afar and Amhara -study participants across different tiers of the health system reported that their supply issues had been resolved after once they were made available inthe initial run on the market. Most of the health facilities received support from a city administration, and health centers in Afar and Addis Ababa supplemented this support by using internal revenues.
Despite their efforts to obtain needed materials, most study participants shared that the PPE items available were inadequate either in quality or, more often, in number. To conserve PPE, health officials resorted to rationing or recycling. At a health center in Addis Ababa, each health professional received 50 masks that were expected to last for 90 days. Health center officials in Oromia requested that health workers wash and reuse masks that were intended to be worn for only four hours. A regional health bureau official from Amhara spoke about prioritizing PPE for professionals who worked in laboratories and , isolation and treatment centers "even though all health workers were demanding all PPE..." In the end, an inadequate supply of PPE made it difficult to follow guidelines meant to protect health care providers and clients, which in turn, heightened fear of infection from all sides.

Risk Communication and Community Engagement
Risk communication and community engagement was central to the response effort from the beginning of the pandemic. At regional and zonal levels, risk communication teams in incident management offices developed and disseminated messages with support from partner organizations and local government communications offices. Printed materials, radio, and television were commonly used to transmit information, with higher-level offices relying on broadcast media. Regional and zonal offices ran ads on local radio and television stations about the pandemic. Experts appeared on live television or radio programs to answer audience questions or present the latest information about the virus. As the following quote attests, collaborations with international NGOs, academic institutions, and professional To a lesser extent, regional and zonal health offices also used new media, particularly Facebook, to share information and updates. The regional health bureau in Tigray, for instance, posted the daily number of confirmed cases in the region on its website and Facebook page. Visitors to these sites could also find information about COVID-19 and steps local authorities were taking to contain the pandemic. In addition to traditional and new social media, health officials in Sidama and SNNP collaborated with artists to develop music and drama about COVID-19: "Artists in the Sidama region communicated messages through songs and drama, for adults and children, on how to prevent the disease." (Sidama, Regional Health Bureau). A woreda health official from SNNP spoke of a "holistic" song produced by senior Wolaita musicians that gained popularity with rural communities. In Oromia, community and religious leaders played a role in community education. "We provided information to the community through religious leaders, cultural leaders -Aba Geda, and different media. People in our region have received sufficient information about prevention and have used that information to keep themselves safe." (Oromia, Regional Health Bureau).
Woreda health offices and health centers commonly relied on printed materials (leaflets, brochures, posters, and banners) to spread information about the coronavirusCOVID-19. Regional or zonal offices created these materials in local languages and sent them to the lower tiers for distribution. Health extension workers (HEWs), volunteers, and care providers handed out brochures and fliers in the community and during house-to-house visits. Posters and banners were displayed in crowded markets and busy streets. TheA RRT was called to conduct an investigation. Following When there wasis a suspicious finding in the community, a RRT was called to conduct an investigation. The team -which typically consisted of a clinician, an epidemiologist, an environmental health expert, a health educator, and a lab technician -then transported individuals suspected of coronavirus COVID-19 to a quarantine center where they were tested and remained until their results were known.
Depending on the region, either staff from the EPHI or members of RRTs were responsible for sample collection. In August, the federal government undertook a nation-wide campaign to gauge the level of infection in the country and measure community understanding of COVID-19 prevention measures. Vulnerable groups, such as those with chronic conditions, were specifically targeted for testing during the campaign.
The RRTs were also responsible for transporting samples to the nearest laboratory. Each region had at least one laboratory and many were located on the campuses of major universities. Before the regional laboratories were set up, tests were sent to laboratories in Addis Ababa or outside the country. Key informants in Oromia and Tigray noted that laboratories struggled to report test results in a timely manner. Delays were reportedly due to a lack of coordination, limited diagnostic machines, and a lack of reagents. "Quarantine is located at another site…. but the problem is test results are not reported timely and a lot of complains are coming from people staying at the quarantine center. Results are being reported 9 or 10 days after they are expected, which is extremely frustrating. …" (Tigray, Woreda Health Office). to re-open. Rapid response teams determined who could isolate at home and regularly followed-up.

Infection Prevention and Control:
Health centers undertook precautions to ensure the safety of their workers and patients. They set up washing stations where patients were required to wash their hands before proceeding to their appointments. They limited entry only to patients, placed markers two meters apart so that patients could adhere to physical distancing requirements, and disinfected essential departments. Some centers had two gates, one for entry and another for exit. "In addition, guards were given additional work to make sure that every client entered to our health center washed their hands using water and soap available at the gate". (Oromia, Facility 2).
In regions across Ethiopia, community-based infection prevention and controlIPC was largely the responsibility of regional, zonal, and woreda health offices. Many installed handwashing facilities in crowded areas. A woreda in SNNP temporarily housed "street dwellers" who were considered highrisk for infection and provided them with food and hygiene materials. A zonal health department in Sidama disinfected sidewalks and office buildings every 15 days. Higher-level offices collaborated with the police to enforce or promote infection control measures in markets, restaurants, and passenger cars. They also organized volunteers, particularly youth and members of the women's development army (volunteer community health workers), to educate and encourage people to adhere to prevention strategies.

Discussion
Similar to many other African countries, different regions of Ethiopia acted early by implementing screening measures at airports and border crossings before the first case of coronavirus was detected (3940). Following the confirmation of the first case, sub-national government structures from regional These examples, as well as Ethiopia's our own experience has in Ethiopia, showned the potential for local governments to play a critical role in public health emergencies and other disasters. As Dutta and Fisher have argued, decentralized government institutions are better positioned to carry out the basic functions of disease control because they have a deeper understanding of community needs, can respond more efficiently to crises, and hold greater legitimacy with constituents than distant government officials (410). Unfortunately, our study showed that the role of local governments was not sustained over the course of the pandemic -a finding that was not reflected in other studies. This might be due to limited experience in exercising decentralization in Ethiopia and lack of mechanisms to ensure continuous financial support. Furthermore, trends in influences from international and national practices trends could operateinfluence and this that requires further investigation.
Initially, the sub-national response in Ethiopia also embodied a whole-of-society approach that was promoted and reflected in the literature. This approach endorses collaboration across sectors based on the notion that no single body or institution can capably respond to complex emergencies or social problems (443). Again, studies from India and China found that local governments mobilized community members to volunteer in the response effort (410,454,465). Also, a survey of medical students, health workers, and community service workers in Vietnam showed strong support for involving youth groups, women's associations, religious leaders, and local organizations in community education, surveillance, and contact tracing during the pandemic which is similar to our study particularly at the initial phase (476). In our study, participants highlighted and praised civic society institutions, volunteers, and businesses for engaging in a variety of activities, ranging from community education and the provision of supplies and facilities to the enforcement of infection control measures.
This was a very good lesson. But, six months after the start of the pandemic, the study participants observed a decline in multisectoral engagement and warned of the health sector's capacity to control the pandemic in isolation.
Because of underinvestment in health care, many low-income countries suffer from a shortage of critical health inputs including, supplies, infrastructure, and health professionals. To fill the gap in human resources, for instance, experts advocate the use of community health workers in both maintaining essential health services and containing the pandemic (487,498). This is viewed as a feasible solution in settings where community health workers outnumber clinicians and function as trusted sources of health information and services (5049).
Our study showed that community health workers (known as health extension workers or professionals) in Ethiopia were a key to COVID-19 response strategies. They engaged in community education -principally through house-to-house visits -performed screenings, and assisted RRTs with contact tracing. A rapid evidence synthesis found that community health workers in low-and middleincome countries played similar roles in the pandemic response (510). Furthermore, when essential health resources showed signs of decline in Ethiopia, community health workers were tasked with alleviating community members' fears of accessing health services and re-engaging patients who were lost to follow-up. In many areas, responsibilities related to COVID-19 were added to their existing workload, creating low morale and push-back from health extension workers as the time progressed.
The rapid evidence synthesis showed that improving benefits, providing training, and recognizing the contributions of community health workers in high-profile events could bolster their recruitment and retention (510).
In addition to mobilizing health extension workers, sub-national health systems in Ethiopia addressed the surge in the health workforce by reassigning health professionals, cancelling leaves of absence, recruiting new health workers, and bringing retired or private sector professionals into the workforce. While comparable research in low-income countries was not available, a study of 44 countries in Europe and North America showed that the governments of wealthy nations used mix of policy options similar to what we found out (521). The most common strategies involved maintaining the existing workforce by extending work hours, moving staff from part-time to full-time, or suspending annual leaves. These governments also recruited medical and nursing students (a strategy that was not mentioned by participants in our study), redeployed workers to facilities or areas with the greatest need, and enlisted retired, foreign, and private sector professionals. Most countries used at least two strategies. While the impact of these measures in Europe and North America has not been studied, our study participants linked a weakening of the essential health services to the redeployment of staff to the COVID-19 response. This mightay be due to inadequate strategies and , prepatationspreparations and financialanatical constraints in recruitmenting of new staff new staff and redeploymenting of available available staffhealth workers in Ethiopiastratefies .
An important factor in containing COVID-19 was protecting the health workforce from infection. Study participants shared their struggles to acquire PPE, particularly face masks and gowns, at environmental obstacles, Most COVID-19 -related studies conducted in Ethiopia examined knowledge, attitudes, and practices among community members, showing generally high rates of knowledge and poor prevention practices.
Limitations of the study: Due to national and state level lockdowns the investigators could not go out to the field thus limiting the potential for extra lens to note field observations not captured by the interviews. However, the authors have tried to overcome this by assigning a supervisor for each interviewer in each region. We noted that data collected from 2 two of the regions was not good enough in terms of depth and probes that affecting the richness in some of the topics. This might be due to lack of experience of those interviewers in applying the different techniques of qualitative methods. However, the impact was minimal as the sample was large enough to explore the topics of interest.

Conclusions:
Sub-national health structures waged a swift and coordinated response to COVID-19 at the start of the pandemic. They drew on all available resources -from their own expertise and workforce to local governments and businesses, academic institutions, and community members to mitigate the spread of the virus. However, the response was strained from the beginning -due to a shortage of health workers, space, equipment and supplies -and began to fray as the pandemic worsened. The multisectoral response that started with strong political commitment and drove the initial response declined within six months of the pandemic. As the number of infections in Ethiopia rise, we recommend: reengaging local administrations and actors outside the health sector, including academic institutions and local businesses, in the response effort; strengthening resource mobilization for COVID-19 supplies and equipment; improving testing capacity across the country; and collaborating Commented [A17]: Why you do not involve assessment of modalities of online care that need extend rapid access to cellphones and internet for health professionals and users. Also, remote consultations with video, since it facilitates monitoring vital signs and decreased the risk of infection. with local media and community leaders to strengthen community adherence to prevention measures.
There is a need to invest in the basics of the health system -health workers, supplies and equipment, and infrastructure -as well as specific interventions to shore upintensify the COVID-19 response and restore the multi-faceted response. The study has illuminated relevant lessons for future emergencies and underlinedand underscoredlined s engagement of local governments is was a key to take immediate action and sustain the local response against COVID-19.
Supporting Information S1 Fig: PHCU and administrative structures